Wednesday, November 17, 2010

Some implications of biologic plausibility

Ever since my... ahem... skirmish... with the folks over at the SBM, I have been contemplating the issue of biologic plausibility. They contend that our tax dollars are wasted by being allocated to the NCCAM to pursue research into CAM. Their reasoning is that there is no biological plausibility to any of it having any therapeutic effect. Now, this is a big bite to swallow. As I have said before there is CAM and then there is CAM. CAM seems to be a convenient wastebasket of modalities that we feel justified in bashing as "woo" since there is limited scientific evidence behind them. But really, I am more willing to give acupuncture and massage the benefit of the doubt than, say, healing crystals (even though I confess I really like rocks!).

So, what of this biologic plausibility, and who came up with it anyway? And is it truly fiscally irresponsible, and possibly even unethical, to test interventions that do not fit our biological plausibility criteria? As a corollary, is there a level of our understanding of biology that makes testing equally wasteful or even unethical? And finally, should plausibility of benefit and harm be required to reach the same evidentiary bar?

For the definition of biological plausibility we apparently thank the milestone 1964 Surgeon General's report linking smoking to cancer. This report was the first official US government document to state that there was enough evidence to implicate cigarette smoking in the rise in lung cancer and cancer deaths. Since the limitations of observational research were used by the critics for decades to derail this definitive statement, the report itself does a nice job laying out the methodologic considerations and the need to rely on the Bradford-Hill criteria. It was in the "coherence" criterion that biologic plausibility entered the picture.

It will be helpful if the causation we suspect is biologically plausible. But this is a feature I am convinced we cannot demand. What is biologically plausible depends upon the biological knowledge of the day. To quote again from my Alfred Watson Memorial Lecture [1962], there was

"…no biological knowledge to support (or to refute) Pott’s observation in the 18th century of the excess of cancer in chimney sweeps. It was lack of biological knowledge in the 19th that led to a prize essayist writing on the value and the fallacy of statistics to conclude, amongst other “absurd” associations, that 'it could be no more ridiculous for the strange who passed the night in the steerage of an emigrant ship to ascribe the typhus, which he there contracted, to the vermin with which bodies of the sick might be infected.' And coming to nearer times, in the 20th century there was no biological knowledge to support the evidence against rubella."

In short, the association we observe may be one new to science or medicine and we must not dismiss it too light-heartedly as just too odd. As Sherlock Holmes advised Dr. Watson, "when you have eliminated the impossible, whatever remains, however improbable, must be the truth."[1]

Aha, so biologic plausibility is a function of the state of our current knowledge, today. By this litmus test, Marshall and Warren should have been laughed out of all funding agencies. Instead, they rewrote our understanding of what can live in the stomach, and how a microorganism can cause peptic ulcer disease and stomach cancer. And got themselves a cool Nobel to boot. So much for the ethics and finances of biologic plausibility informing meaningful research.

Now, on to the question of whether there exist relationships with such high biologic plausibility that they do not require irrefutable proof. Well, how about tobacco and its health effects? How about radiation exposure? Now, how about what we know today about the evolution of microbial resistance to antibiotics? Is it enough that the biologic plausibility for ill-effects of antibiotics in our food chain is strong? Can we now stop the madness? If my colleagues over at SBM are given to the same logic, they would say yes to this. However, extrapolating from this post about organic food production, I somehow think that they would not. So, I am guessing that, although they believe that lack of biologic plausibility should preclude attempts at study, they will nevertheless be reluctant to set a threshold for biologic plausibility that might obviate the need for further research. I am just guessing, and would love to hear what they really think.

And finally, what of the plausibility of benefit vs. that of harm? Should our bar for biologic plausibility for harm be lower than that for benefit? Well, the question really boils down to this: How many bodies do we need to see lying in the streets before we concede that there is a problem? My point is that we Americans have a hard time subscribing to the precautionary principle, applied generously in other parts of the world. If we were a tad less reckless with our need for irrefutable evidence, how many decades of equivocation about tobacco and cancer would we have avoided? How many lives might have been saved? Biologic plausibility for the connection was known even in the 1930s, yet it took another three decades for us to act. What are we obfuscating today that will come back to bite us (and our children) tomorrow? Could it be the cynical injection of doubt that our food production system is causing irreversible damage to us and life around us?

So, what I am saying is that biologic plausibility has several facets. We have to admit humbly that its assumption relies on our necessarily incomplete knowledge, and denying this may prevent us from awe-inspiring discoveries that will advance science in leaps. However, if we feel strongly about the need for it in order to justify our research allocation, some careful soul searching is in order for those thresholds of probability, especially of harm, where we may admit that science makes us sure enough, and, instead of awaiting perfect evidence, we must act promptly.

Welcome and a disclaimer

Welcome to my blog, "Healthcare, etc."! In this blog I take the perspective of a researcher/policy wonk rather than an individual healthcare practitioner. Therefore, all opinions that I express and generalizations that I make about any issues will in no way be construed as medical advice for individual visitors / readers. All views expressed here are solely my own, and do not represent opinions of any organizations with which I am affiliated. I welcome all comments, but reserve the right not to publish paranoid or abusive rants or overt marketing pitches.

About Me

I am an independent physician health services researcher with a specific interest in healthcare-associated complications and a broad interest in the state of our healthcare system. I am also a professor of Epidemiology at the University of Massachusetts, Amherst.
I am frequently invited to speak about evidence-based medicine, methods and healthcare-associated complications.
My posts have been syndicated on The Health Care Blog, KevinMD,The Healthcare Collective and other sites. They have also been cited in the New York Times. Occasionally you can also find me blogging on the British Medical Journal blog site http://www.doc2doc.bmj.com
If you would like to contact me about my research, blog posts or speaking, please e-mail me at Healthcareetcblog@gmail.com